Mecklenburg_Well Abandonment_20231113

WELL ABANDONMENT RECORD For Internal Use ONLY:
1 ,
1.Well Contractor Information: WELL ABANDONMENT DETAILS:
Jeffrey Grant 7a.For Geoprobe/DPT or Closed-Itioop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4328-B wells abandoned:FOur
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '1 (gal.)
JG Drilling, LLC r .
FOR WATER SUPPLY WELLS ONLY::.
Company Name 7c.Type of disinfectant used: I
,3,.,,
2.Well Construction Permit#: WM0301326 { NOV Zl
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: . i'4'a
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
0 Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry . 0 Other(explain under 7g)
-----PI Monitoring Recovery-
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier -
❑Aquifer Test ❑Stormwater Drainage Bentonite 30 pounds
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Fill the entire length of:the borehole with bentonite.
4.Date well(s)abandoned: 11-3-23
5a.Well location:
Heaven Sent Catering/Shawn Kennedy
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2300 Beatties Ford Road, Charlotte, 28216 11-3-23
Physical Address,City,and Zip Signature e t We outator or;Well Owner Date
Mecklenburg 07502106
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.265268 N 80.853855 You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: GW-1,2,3,4 abandonment to the following:
{
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 22 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: '
r
6d.Water level below ground surface: 18.70 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cetiter,Raleigh,NC 27699-1636
18 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the count3i health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 4 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016

Mecklenburg County Health Department Bill To: Owner
Groundwater&Wastewater Services
3205 Freedom Dr. ��Ro 10/30/2023
Charlotte, NC 28208 Permit Issuance Date:
Phone: [phone] s I 1 70003171
Fax: [phone] Permit Number:
http://aroundwater.charmeck.orq °q" P
TM.CAfNO D.
SUBSURFACE INVESTIGATION PERMIT -�`
I. Well Owner Information
Name: Shawn Kennedy
Attn:
Phone#: [phone]
Address 1: 2300 Beatties Ford Road
Address 2:
City: Charlotte State: NC Zip: 28216
II. Agent Information (if applicable)
Name: Trevor Tucker
Attn: Trevor G. Tucker
Phone#: [phone]
Address 1: 5935 Rivers Ave. N. Charleston, SC 29
Address 2:
City: North Charleston State: SC Zip: 29406
Ill. Site Information
Site Name; Heaven Sent Catering
Parcel ID Number: 07502106
Address: 2300 BEATTIES FORD RD
City: CHARLOTTE State: NC Zip: 28216
1
General Conditions of This Permit: -
• This permit shall be VALID for a period not to exceed twelve(12) months from the date of issuance.
• This permit is VALID for the site specified above and must be on-site during the course of the investigation
and made available to a Department representative upon request.
• A North Carolina Certified Well Contrator must perform any well contractor activities associated with this
permit.
• All wells shall be constructed and abandoned to the standards of Chapter VI,`Section V and Section VI
of the Mecklenburg County Groundwater Well Regulations.
• All temporary wells, including those installed using Direct Push Technology, niust be abandoned
to the standards of Chapter VI, Section VI of the Mecklenburg County Groundwater Well Regulations.
• Registration information for all wells must be submitted to the Department within thirty(30) days of well
completion. If water samples are collected, it is recommended that the well NOT be registered until the
analytical results are received.
Page 1 of 1 SIP Form—revised 2/15/11

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�'VELI�ABAI DU 11tIENT RE QRD Forlydcmilvicet)NGY:.` I
"This fortti ran be us<�d,forsfaglt or nmtdtrpie arils
•t.S�'c1t C'ontr,,crnrTnfarn6 n dn '. • 1.40: T,i 11ANDorgblFNTflFTA t:
•Rich Lemire • .ya Number of ells bein g abendo+std 1
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CknptN1c. ., g.r- xnp ••;I •j ' Cn23`'2Well:Cunstc Misr intt1:700 '..:
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«'afar S�pp•' Wetl •• • • • Seabtig nt t rial aced(eked all that apply)7c tc
OAgrtculiunil f�hitnu..plUPobfr : tl is Cbipc iirt'c.11ets-:.
Glt C ctvent Groat !,`_ ento••• -
D�riith moot(lieannrjCdoling Suppti) • Dfacsidentiai Watcruppl)(stnstc) D Sand Ceutent(nrnL El:Dcy Ct.v
olratpstt•iiftit omiiicreiat.. ••• • • 171tcslclentitil Wa10Sllpfp1, (shed..} d Con�n to GrouL ❑Dull Cnuings':
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•
Dtiii tiou- • :. [7 Spec3gin Grout:' El Cratel
:- Non-Water' .ippi}Well ` .'ii Tenie?nite 5turt ::_ El Otfter(e hm•under..
•
Injection 1Ycit • • • •• • • • • • ;71 For eacl►utaterla Selected atmse prude:imauritofniutenatsu ed'
OAt(utferRecl4arge 17G nndct1 terRcut itanan•- ';
•.. 0Agui1Ai.Stortge atxt itc u. is OSnhuut r horsey
z Beritonite :15 GRANULAR'.PELLETS1b ,Wtr::gal;.
: [)Aqutfet test • • CiStonnauletDtariagd:. .
D1 pnnna nlat Teehnologtf D$ubAitenee f~otrtrtit' ;.•4 1'rpsidC a brief dttcrilition gf ti c abandnnmcnt proi Frlun
DGeoihemtal(CtosCd Loop) t Tacker " =
?PULLED.HELL,'OUT OF,GROUND.AND POURED GRANULAR BENTONITE:IN
> Geotft�' •fiH dnvle.otiir Itetarn) 1 Otber(e cph iuiuler70•-.: . . ,. - •
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` - I30LE'TAGGING IT'WITIi TS,tEMMIE LINE:: FROM:BOTTOM TO:TOP.. •
# T)H3tC CU(S)9b uidoned' • ,
$a.Well laeahnn;. . . ..:.,. , : . .
FORMER•DOMESTIC LAUNDRY
-f cftriu'th .rNuiiicl • Faciiith`ll}ttit' pixablcct • • 8 Ccrttt cattm
ap ,r 10/22/2023
801 S McDowell.St. •.Charlotte,.NC 28204 .•• • •
Phls"reaIAddres:Giiy atidzip. • ::$iv:hiur.ert , iH d.WellCnrur<wtt?rotWeltfhAn:r: btu .
MECKLENBURG' : fly •••nlni d••'•'-' • t herehy • '71-f iltat to•atell(s is�s �it°ePe}nbandaiu d tit
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'Gaunt Panel l&nuri t>en fo tN} ucr[mrktnce rntlh LU VC AC 1)2C 0.N..4 ctr 2C.09d0 ii i l(Ctnslrrtaw,:.??- rds
'and ccopyoft • prtt»sled 1e tPtece'..ownr ::;.
;5b Lat>t:udc.and:longitude i degreeshnh ut&secnn�dsnrtic*im tt dettrrees. 1 ct(u r rzanm hrrsbecri Jr Ir
(ita r 1I t?1d{trR yfiltpn t4s l?3cu r!) :rl Site dtagrum or addttiouafwell iletliis
. .:. It=: .•: . ' . .. R' .;tbo tone eatdelail��Y•ou al l lbcbr tfinntialtlpagesif eessat� ls'oe ttll
• C.OfiTRIH(1'1OSNt:bl TA1i..(O1r•�V1;1,"1.(SI•BkiNC ABAND(1NEb•.. StIA1 rrrA1,1 ISTRt1CTiON i, .
•Aflaslt irc�11 c»tts. 0.04.0 rs tw...,.FPniAt..0 4' 1"wztud1Lig fi..Y i7aa W j'ivHtKkbtrY lt�p1} •,
:It'OWtl l ilk ilid ame6km tlfarta irtrl4f.0.ri 0•0 rate uit04:0•t•O• i � ,10a.boy.`All WWlll Sub nut tine••:faint within 30,1:4).1 of con pletion's f ise l
ilhjtndontpcat to the tottocin
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Ohl*ton of SVatrr Rcsnuitc,Infb.rruatton_1roee lug Unit,
i6t17 Mail S•ec vice•C4ntcr Ralciuh AC 2'I699:161'•f::
6bofalsielidepth 15,. (ft;4:`.. , -
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1at) ticit`Jfnteetintt Wilis ill addition tb sendin thelonu tb the addmss lit It)3::
6c.l bretiotc dLtitpet r:l' Diu), °nboi a also submit one caps of tb fornc► thin 3(t da1.s of eo uptettan of►sell
. . 'ibaudoiuiitnt to the fallofiiiu
Dh istou of Water Res ontecs.Under nd lnj ttnn Contrnt pragrum
6rd Water tcicl beltixt round surface NA (It, 163t Mad•Cenice Center Raleigh.11'C 276'.) IG3G
tOe Far••syatsr rimnii &7ateet n Wdte hi-addition to sending titefonn'lo
Ge Outer casingtcngtl1(iflmon'n):.' (Oi} • itte oddresstes)'abote, also,sttbumone cop), of hits lomi tertian 3t.lows of•
cotnptsuon of n`ci.l abandonment to•the count• y• health dT4...•ant of the count}
•bf Ynnertavhiglinbtttg tcngth of laiosrn) -•. (fit:)
c here nb'mdots.d.
6g.Screen length(if fmuwn) 10 •.(tt)
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`Form(1W-'in Noah•• urotiia D rur�nl of k'.nt-troarnerawiwi*twat itesouric lslslonof-Wier ahT garcon ltc iscd Aug�xst 44t3 : -.

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:WELL ABANDONMENT.RECORD.: . Far U ONLY
'This fo i tf nbe used.for sii to or a illtipie w lIs` '`' .
I Wci1 Ccintraccorinformation, ':1VEI L ABANDONMENTtETAit , • • • • .
Rich Lemire :7a iNumberofiveIlabeittg.abnndtined 1 - '
-:VYeiIGnr i�iMorNaitie(ar44..�,ttmrp� Hanish iititaninpuJlonl411jafpruCieti}? ` mu..Vf. , ?uk+tvtar r{�::, twlt tnf. �...0 trcMlt...O%t)° ,meth tlti ': ur;
ciiotii tttus'okti lnuriaattt)vtti L t.vlutit[utc ei.ip
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s FORWA'D Rwvri,Y'1« ONIiY ` tr.::'
SAEDACCO _ _.
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b: dIt,p pre..... 11 srmily lr .P.aa'uit Strife)attires illOtl.u.rfIJ ,triuwri . :in or n>> .•
7d�Uunt of di�{ttfcctaat uaY�l..�
• •3 «tcdl u (chWisitil! ): :- 4,.� • x ;•
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• CiAgntulfnrat t7)tilisn:cip ii/Pubti� G Ne tt Gciuerit G m t G9:l3emaniteCbrpc or,N0d s
•;: i]Gcathcrnxei tHcahnc7Cootiiu Supitty O'itesrd nha{Water Supply(srnsic D Sand.Ce►nettt Grout, - 1tI Dry Clay i
• Otndugttia1.ComricrcraC ' 1DResrdenti;ilSVa:erSupplvafsh;ered) 0 •Co11ereteGrout. D DnllCtittin •
D'Ittiiwitiatt
• D Spser5lty Groui l7:Grasel
:.N•on.WaterSupplyWcti • • - •:'U.fentareiCeSlimy.+. Gl.`OWer(e,Yplatnutaler7g ` .
DMonitoiing lDRecot'er t• - '
Inacetion%Veit ,:•7f For`ea•chniat•eriatsciectcd als•o a 1iro ktc•�eniount`aftitater olds 0oe,`'
[]Aquifer TiecIiarge OGrotusdst:iterA0iiit iia►rai . '
O404 iStontgiytii4)*Iir cc OStdauu 13amer. •
. DAqurfri Test DSton:iic'ofi.rDral.Og •:. . •
: DC, erinientol'I'cLhrtOigg .. •❑Snfisiiki.e Coi..ru1'• - fi r Vmtide n half d cccrtption nftbc atrunclnnment hlnictdurc
:': :OGaothermal(Closcdl.00pi t Tracer
r.. Well etas "destroyed" during on-site ,construction activities;
• t Geothcrrual . eiitiug;CooUtiaReturn)'.•. . •`O Otber(c,�'platit'uiider7g) - .
"im o ed" .
Date jfel. l(s)abandoned;`10-20-2023 .•:. .. ._ : . : ....
5t.-W,01.1orat{on:: .
FORMER DOMESTIC LAUNDRY: ;;;
• • (f , $rC rticatioli , '
e:. c]rti.-I rNatPe FarityW# iuipi C1,. a" ,I . r
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801-S.,MoDowell.St. Charlotter.NG•28204 -• - ..:
'Nit sit:Addrtt.,e ty.andZip . . .: -;:§!0.iic iC! air d WcU( iitrn.tar4r)We71 Ch-rx:r I7�te 2 .
MECKLENBURG • • ' I3v otgtrti,g this foam, I Iterel,l cirii/V iliui Ilse W 1lI.ct isers firer ,atintrduncrl.in
.t~ouoty"° . . t'-rrcl ld„ntii sii inNo(tn of wriiiiik oral+t A\'C IC 02r fi1Q1)arc:• -:%.0(rli)t'iCon llsr tl%tiritt ff,nd arih
' vnrl of thrr reccrrtf lube ct,su' pirui-Fileil to lb..ttr11 ms'ntr thrit;ficf,��r, ,
4b l.sitiltidcantl.longztadpin dcg►realm{nit.O.,scmndsoc th ui.ii dcttr,0; .
(Ct i cdt f`riid ui?�t,,1tlkru. i_�sttti3ars�,i • •• • :9 Site.diagram ar addlhonal well de.t111s
'Your ii,ay.me the;Uae).of'ttl{s pn a to provide addrtiotal iu.11 site details or vial•
-N;' ' ' - A}• abiiiid©innerit'daails You may also::itincti additinrial lk'iges if I essa1 .
- CONSTRlitlit)N DET,AII ti'f1F-1,VELI4S1'Hi ill( ABANDONED ,. ;,S'Utilvir'T,Ai.INSTRUCTIONS
400s:iicl(rnt,atr 441.4rt n6x,rtI ,l ai i.ii(04. 1"iv irurltrple O i i iirr UI. ,ar i.i, rtf 'I /1� ::
...:i.M. ONXYiiA4ii.i. vreruro aeui a`_;41, u..Iua iv`,.Ot�astrw i riirt.10:14Ya :;1tta.For.All 'Writs Submit this films within 3t7 ddys 4f conipiction;rif i-I
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Ga \�ellPt)ll Pz-1 pbanioniiren:to the folllowinq ---
Drt kkE n of Wate r ltc uurcc,Infi rmation::Nroce.ing Unit.•.
. . 1617 tltail Semis.Ce inter.Rale`gh NC 27699`1617: - .
Gb Totatwell depth 25 .. (fi.),=
• Ittb F(irtnleecikiti Wclis 1u ndditioti to seirJrrig tb f'i nit to ib. addie s'it,I4a:
Gc 1 :n)' above ,also srtbndt one sip'of this'form.iiytliiit 30 dais Of conipletroii of+ill•
.
Borcbole dlamete�r: C _',rb indoiim nt to the follotv:fit* .. 1 -
• •
Division of 1Yater Ri oi ures ,Underground Injcciion Control Progran)
'Gil.'V ater level belovt around surface: NA •. (tt,.) .1G36.11t ail Seitiicc Ce►ter RaRleigh.NC 27G19 1G36 .
.
•
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to Rie.11iatti•Cirnoiv &Iniletiitir WellF In addition to wiggling the form lo.
fc Omer'casing Icngttlf(iticnotrn) (fi:: dress()abota also aiibmil one copyy of this=;form riittiin'#U days of
t1se .id
•
i s Mhiuul f (1 nb u►sant o#the t ro 4titdor. o.iiity'$0.1 dC*-lni o of iHr:.coiloi
41.inner! uia titbin len' if lniovrn 00 tvl
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,Sct�eeti length;({f Imuvv�t7.i o '. ' �.ft 1;Gi;
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\' .ELL.ABANDONMENT RECORD,. Pcirlydtrn ri t} :ar;> :
Thus foam Mtn be usedtbr single oraiultipli>.Nitts :•: .:
L Well'Cnntrrctorinforanatlua 1�'>LCi i1�A1Nat)1� 1 NTDECA![ ..
Rich Lem-1re 7o NrrmberoIeifsbefng:abdndo ed 1
r :..hc' 'onion r ttta'�tl o txtw rafts uy.-0.• air t 4(Js�;;ONL)' ._withh. il-i4'''titer.
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t.�tire ttthrtttrbntrdtwirtttmt Attu��l gutwtit tatc�jcjrtit
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NG 1Yc11 Cfintt 61.•oi rii#411.i3nl3u00
SAEDACCO FOR WVATERSt1PP.t:;YWFJ,LS ON Y -• 1 : •: ep2
.CP:itgO y- - 7r,'Ca'0 40iaintcxtant died 9 •, .
'.2 %t ell Cr ustrucifon Per nit#'7 o 03118,
Lee dl4 ppf cis)I u N pern 0.0, Cui nt Sri furl 1,J&6t1i,':0 t:lfl wwti; 7d iS.n unt or•d•isinfectant used. . . .• '_D_:•
)`•.-.-', "_ . I.!, i
3 Wclt u+c.(dicekwt.U•uire)
NV ater5ppp1,3(Well, 'lc 5Cafing tatatedats used(abed.alt that apply)
❑Aerrcis1ttnat t]lrlruuerpilt ubir : l Neat Gcnteut frmut D;AcntanitcOupc or.NUcts
' i>emi t(I cutrn r(,otIn Snpp4) tlRcsrdonti:tl titer Euppii(s ns1c) : D Sand Cement G•rout; . D:Drt C1
0lriltis1rla11Comircri nl. D teslcleittiai Wafer,Suppl}(shared) 0 Concrete.Grout:: o. linll Cutting
Dtttigtiaii ":. ... : .... :". .. 17 s.:.1.i3lts Gttiut, : 0:Gwdtcl •
1Von-Water"apply Welt _ :ti Beoto?ofte-Just >': F .Other:(e*tplztn•under 7 .
iiMoniionng . . • t7Reco t-eri •
: Injection Viclt .. .. bore,ptrotiide:inmuut of.tttatetialctiseil::'':7f.�ar'cacb r►t-teri d selected a
0Aqui0 Recharge DGru414ii�terReutedifltion:.
❑Aquite"t Stor iv:and}ftctnen;; oS91n lh Datdcr :. : .. . .
4440Test 1]Stom*AicrDralit ' . .
: DRprinteutol T clruoto,g DSrrbsidette CoretriM' • .gg,pm'dt,a brief description•ofthe ab inilonment p 0.i.iiun.: :
t1GQathermal(Closed Lvop): OTracer
• Well was "destroyed" during on-site construction..activities;
OGeothenrt tl itt£ tina1Coal►iretetotn} P Otiter44:1;un udder 7k).
.
. . ..... ... .,•.,.. .. ?. roperly.;.al;andoned" . ... . .. . . ..
-.4 c DateU(s)abn adoned::10-20-2023 •• .. . -
5a.�Yctl location:;
FORMER DOMESTIC LAUNDRY . :,;: .
r 611..0iVit T44iittic. roplit.uP$ rfa` t,-at•t ••-:8 Certitt•eatlat
PP --
'-801 S..McDowell. St..,.Charlotte,.NC- 28204. .. • • " J : • .. t'^+*'"G' ... 10/22/202
:Ph si al'Add[c ,.c aridZir . •,•". - i•, : • •y tiit�+(rt'r r11 d i1/00l*tti.*V1:Cll(hir r Uti e:
MECKLENBURG 13j,ct ntliie this,fd i 1 herabp-07.(i,fy,tort the bt 11(�,)s sns('it+ei`r}abnnd ii6;it
4
Coanl .: t'Sccei"1&ntiri 1:(1.4nNo 01.0 llccorilttti sa teal+It4\TC;tC42L 0t1.0.O ar2C' (0 Will('onttttirctt.0rt5iandard.,
ndthniitcopyv, `tlitrricrriitlinebeenpentzrleitleit ewellon;if,:':
.50 Laiitudcand)ongitude in depreecslmrinutealscctrnds ordecimal de>;recs
(trwytt livid u•t?i L.1t/l•ii.#• 4 0rinein ) :. ''h Site diagram g badditioriat cell dot-ills
. 17tnt k;lit:tile; ail.of ibis pa ;to provide addihoiiai its it sits details ar Drell
N). • • • • Y.. .:abandonment•details Your.ua}also:atiatb. phonon p igcs tf.lleec5sal ,.
• e.ON',5TR11C:mils ii t t1 S t1F'WELU'Sl'iikiNC.AitANDOMLD .. ;s.uit11t17TAT.Tlti57' gMciNg:.:
.tttndr 1e11 rnitsirat'iOt rccwrtl:tt ltoistwkb(e t'rriuublp1.iitk is t, `i'wi-nrua' node . .
"wr•e)1s4).V. . icUtilu;sattrcr�tKm tl�rt ire tr ?4i;,tvttruk'1�eltr c �rrrr tits.ltnr Alt +itiit Submit this(omt within 3t)dzi• }5 9f Completion•of•�stl.
6a.�'Vell U) PZ-2' abandonment to the fallaitriigr ,• •
Dh ist to of ilVatcr Rcsaur e4,Information:ProceMing llnit,;
Gb Cool iscli de :th 25 {. . 1617 tltad ScA,Eit Ccntcr�Raleig h l C 27679 1617
p ( )
-.':lob'Tot`•Inlectioiti Wc11s "In addition t0 setidittg the fai)ii to the addriess..`in tOn:
6r Borchalc dl imet4*r 1 ((q,) : above cilso subntit one cops'of tlicc:faria"t itliiti 3t1 inks of coniplerlort;of ti 11 .
abalounrar to the foUoariit,, I.
lid W.iter tenet hclo►t ground surface.NA (t.:. - Dil lslon of W.ater Resotrtct t Under round Injectittit Control Pro gr�urt
1634•At lit Sci+iccGifcr Balch t ?iC:27691 1636
• ;ttie For.W• atSr.Cirnnh y Inleetroo 1�'c11� ,ln addition to sending tlic fdtru to •
Ge.Aa tercasmglengtTt'(ifl utrn):, (It) • ;the adJess(es) ai:a* also 3ulinnr one eopy of this faun Withrri Sit t th's of
e iuplstion of sass abmtdai mentlto the eaants lieuttb..dcparturciit of the county -
15 :,t�lr.:rc ntnndoncd; . ':), •6t Inner easingttubrng 1cn0rth titta oirn) t1't
' 6g.Si*een length':(if kaoligi)':lt) • • • ((L). • 1
Fortnt3C1',#i9 Nurftr arut3tnfiepcc[tmrnt;ofk'an1ronro2ntmt92tattuaiRcso -cs lThtstnnnf rater ounrs it6iscdAupust20t3

NV:ELL.ABANDONMENT RECORD: Fditito ukSoNrx.• • .
'Thus torut can be used,for siiigte of uiuitiple rt0ls '..
'1 W.c1l.Onntr.►ctor In formation' `:WFI,L A*MiflONMFNTDETAIGS • .
• Rich••Lemire 7.i i(uml►er of trills briny ,tbanslutted •1
Well Coriiadorhaae(orndli;nure: tseaall)idiuMonlna:iteTlanls ,i)t rprepen>): :ku1` niiit'iii • br�+ttlrur u+r.•itwt}s�F t avpt'¢' ae(ir. "`O,VLI'•:'with it ::,ctkir#
tntarrrrrttierrdiru t(rutiricirt}�trt caRiWrt l tutz+torttr
2593A
'lb�A tei►xfinsite tobune[f s►rtcr r in.unin :in ivaisVA. . ( L)
•-N0;*tli CarltntlorO tit.i4 60(1 f.0.: S:`
.
FOR IYATERS.IIPpipyy ELLS Oh Y; , . .
SAEDACCO _
Camycaiii itna : - 76 r p of disiuk0Ont nscd -. . e y -.+
2 \\i.l Cua3ttuciion Pcrrutt# 7003118, - - '
I,Or�rrrit,tte�trrrwrt N0V .2�23
1 inrrrrS�v li e Cr/**!.!i Stie�c 3lirtnrrce,iir,4#014 r.lrJ'`tldnrywri .
td:Amount of ditiinfcctaat used.,. �.
:r-
? Wdtust.*(thcd trc8 uxe} "- C:
i -:'7c Sealing nirterialc tised;(cbe .dI tb-it appit)
N Atir Siipplt Wea;.:. ..; _- . ::.
DAgncitlttirst t7141tmrclP,1*btrc,, " :`ti NeatCenteut Groat• b3;6cntontte Chq►:.ortibets
`: Ci6:61,6 mn,it(ti'cotiiii C:oc►Un SupptF) tJ csrdeatialWater_ apply(srpblc) 1 SandCementC,sixiiit: Cl:Dt Cbw*
•
D1adiisttititttorruitcrcidl [7)t0dcnto.SVufct:5'upply(shared) Cl COtI rete Grout.° Cl null Cuttin :-
DTitiptition - :.• Cl Sp.inttr Grout: : D:Grdkd •
'1\on Water Supply Wet.:;_ • • : : • .': ."c 8¢l4o111te Slun) • Cl•`:Other(explain under 7g)':
cMoniidiiiia C]Iteco*4, • .. • •
lnlecti n Wel1, 7f For`each nnateri tl selected abosc ptl)i�tdc::imouut'e1 ntate•na14 mot.....:
DAqu►fer Ctcchsrge C7txrouiidri iterketue'dthtlon
•DAitnidet Stora a•atxl thin ci. DSnhalic 13amcr • : : " . : .. .
❑Aquifer Test, . Dsfontnipterbrain s;... ;: •
t7E<pPrirnentat
e Telnolo DSubseice Cuml - 1Proi d• • •• a brie decripion+pftheabandnnmntpr r «lucd " e
.1Set :mtat(CoedLoop) cTrae Wel w:as "destroyed" •during on site construct
ion activities;
ClGeothnnaltteiitt�ICooluReturn) loiter(e J—un under 7g)
ed'
,,imprbperly..abandbn
".4 DatesdflO:'Ibantlonedt•;10-20-2023. _ "
:Sa.lYcll.;tise.iii46.
.
FORMER DOMESTIC-LAUNDRY •
• 0iNyf0i0t;.010itG F .ilnr)py(ifnppt34itilct $ C-.;.., sitiDn,
, , sa
10/22/2023
-801 S McDowell St. Charlotte;.NC 28204 - ,.-g/M •
-P1 stealAddress,C'if},and•
Zip•" ;MPJaiiuz~yfi th d WCtl t oturi,.wr ur tV ll.0-n r. " . p''-ie
•
. MECKLENBURG • •• 1,3} sr• ,t)tig thrs,/orzn• I lrei by cr:rrr s that•trte:iell(.,J inns:rrei) han&rned j,e
-:Cawnt)'; t'arccYt•kntiCa: ? hfa•(Pnr) l cuirrrrii&iridt I-Vt\CitC ir2C t 1,O ur?e 02O)ICdr On Sirttcttort Sremrkrrd • '
.'
'tnri lrrnC it cd}i)s o,f'tliirt ccortt hm baen prti1 trt0 to#`fa ttiV-rl t»snir:::
5b l..iiitudc.andJongitadeindeaireeslnrinutcsfsccondsorttccioaatdcitrces. ,
(iti,elirold)ouclr4 ngi•asvIIIJ(iZt) 9 Sit..dl:rfi•tuttforadditionulwelldetails
a)use ie ' f ilil to ttddtttotkatie�ell sites details or Biel
You�,. t1 back n s page.. pravtde.
. N,'; "•.; '... ' :. W mbar dotunent detitils You;ina}..ilsottuch adcliitoiial pages if imece ssan°
C(INfi'Clittt"17OAT bF`CAtt fi(1F W'ELL(S1 BVI1 f ABANDIONED-i
SLUB.w'1TAL•INSTRUCTIONS
@ttadi:Olt:naitr4 nrrir r Ifoe*...1ria itisltperi*rcmoamnruppr ,
" :ii 7sLN1Yrdlrtakthacrrimttet`dv4'00 40.1:r 0 e1tr110 * : 10.1 P'tir All W(lls Submit thiseint iriihii►3)daysofempcti ntfnicll .
6a.WcU:TD#PZ-3
abandonment to•the•fohoniii
Ohisirinof\VaterRon Information:Processing•Unit,.
p 25... 1611 Mail Service Cti:titcr.Ralrtgli4 hC 27699 16f i •
6b:halal„ru d4 t. ; - {ft,••:: "
lOti::rot-"Inlcrtttit)\liens In ndditton to sending the::fot*to the addr'ess:in tOn..
. • n bot}e,iilso submit one copy of tlu9:;f ornt.wittii>a aft da}s of eonipletron'of'well.-
`6c. beiliele dipinietein l (°) .
=ahandaninerit tp'thc follotYiru "
Di'islon of WaterResoti.* , Undei ground)n colon Control Program
id Water lcicl befog ground anrfaee NA - (l') .1630Aiiiit Scrsice Center Raleighi..1tC27699,46:1i . .
tOe Fur'-Water.Cairin1 Sc:tnicsltoirt•\Veal _hi addition to sending the:form to
•:&c.Outer caslag leng is tit.aron a): (ft} ' - the addresses)nbos a also s`ubnitt'one i.op- of tins fomt within 3B.days o1''-:-
conrpletibn of hell€ibandonrnent,to:the unts h ealth. epitdn;c d of the e nnnt.
.bf Innercat iint;rtubing length(if bnoi,n) 15 Zft)
•
itbtic itiandorie.d . .co
•
6g Scree►i itngth;(if Wiu►in) l0 {ft.)
Fonu(lW--ul • Non tacotiimliepanirkiro12w1ironncartnul:Nuuia0Itesourccs pi+Esi icifyin ritcsoatvs 4fexrscdIu us*Oat3
I'

:.:WELL ABANDONt1V,IENT RECORD.: '1 orlriic ii..t3.....3L .
74 rgiiit can be'used,for single ac rttirtttp1c-ells :: ,
:1,Weli Ci ntraCter xnfirrn.ttroa"` ' fs : BAAi't1t1NMItNT AETAIL
Rich Lemire 74 Number of rtillOttiiit ablit t cdi 1
ttkc
li•Ti t Cc dgrh"atni (or4 11 nes p. niiiil— .Sl siitti-riing a 3]on :l .rprop .3 mntrp fd bff.ot N ror:a :ray t f krf�' aii,,iin y ±a fi _,-.0,\rL}' `'UUh rl..• sr�iin}
clrra4lttttiiu utt�Pnnirrc rtt.vtat�: tt s! sit;turRrr ;
2593A
NC AY41 Canttat rnton+ ttigyAiNtm id
71r.AlppenYnn�tn►ulunn.pf water remaining In nrllta /A g rt j.
SAED•ACCO ..•... A'ERS.I11r.PLY 1 F $O$LY ` -
• • • �(1ft W
c44.am-N mt, _ :' 7w T, s of di:01'th* n.cd .k • - . •h
•
•
•
•
•::2 Well Cunstntctton Permit it!7003118, • • • • • • •• • NO V � 2
.14i0rtp 1kvhfr 11 't'mtt ii C0tiiti Stec t itid..*tr unk�lclif,lr0141: .
023
...; 7d A?rnbant of dlsltifeetaat aced. �
s 'Wetl arc(chcd.wait uM.) r Li c.
• Water Siitpptt Well, 7c,Scaling materials used(cheep all that apph)
l l4hmrci t3 Neat Cement i rittrt b1)eotomte Chips orP llets
bAe�xittDmi •• p1Jl'Dbttti
i7Cr tti ttil l(H iiiitw ooltn Snppt3) Residential WaterSupptt(sii te) . &oast C'rruent C 10ifl: II Dr)C1<i%
[7ltultisttlaL ►ntiiet ctal gltesiticrurtl 1Vnteruppl}fslt�tred)
P.COneiIta Grt II't)rrll CDuings`
••-• Dtttftioii • • ;❑Spy i31n Ginut t7;Grasel
1Y60-4Pater SU 1 Well •pl}S Bentarute Sltirty • GJ:t711ier{e.pl i.. under..
cAvfon1 tinui tlRr ar*:nr
lDleet ti Well ; w p c
�7f Ivor caNt ntatGri it sctected alto idc nttinunt:tif materials iiscd::'
❑Agnit'etltt'ctiar a DGratustts.04-.4emed1.`rtiou •.
l7At ifcr Stonrge and•RicGc err,; DS 1uiiic Darner
• CIAijo.4 r"i . . UStoiitiiv LCrl)Tl.itnlgd:..
#. .hr ni*„. tOdi•OotcsgY" OSarlrside Ca et rctrt►t ' .Ig Pn►s#rde n brief descnrtian of tic abandonm pnent ctdurc
DGeotbennal(Crowd Loop) , 1 Tracer
'Well was• "destroye.d' during on-.site construction activities;
dtleothietrnaltHHc d1iPiti lrua.Utetotn) P.Otimrfetplhiinutuier`7 '. .: ..•. .
• ro erly.;aban3oned
7)atc 10-20-20
rctt 2:3•••:
(z)uhiinilaned :
Sa Weltaoeattan
FORMER DOMESTIC LAUNDRY.:.
. P r41.01*1-Nail Plc.f1t111-Plc. -.00lr:t 10:
• • • ;8 Cert 944tii)it .•
801 S: McDowell St. .Charlotte;.NC 28204 =���. _. 10/22/2023
.Bit:.t a1•AtliWst:Cii1 andZili • • catil,irp.ari e041.W. f,o p t.or 4r'..,s.(Chii6 r crate. .
••
MECKLENBURO :,✓3y ix nlnn thrs f i t lrrn diy c �fi y rived mrca hellp)was(were]ahnrrdoonerl rn
Oi.iit ,, l'an ei 14,.ntit ea tiiCP(o{Pita) ...: 4 aricifrt a wzlh I fi rC.IC 61C 01..4I ar 2f. Il l r�n ut�ualrtr Yrxndard
d Ciu lltttt+iE cc+p}w o,f'lTrrx rt�i rd Iras bi�n Pntivrd. tm 1Frr 4�fI1 tnrrrtrf
b Latitude and langrtuc(G tit deer alniinutc5lsecon4or deer ii.tl degrees.
• (ifas.lr t`io4 ttrw t niiii isiiii*cr*t :` • 9 Site diii tacit oradditional well details .
1'oii iay iii tDhe.b ri k of itiis page to provide;additional rill site details•ar ttef.
•• W.. :;a•b"g iaiuiie tdeialls Yoil`ira•}abo.'iiii ch•.a•ddltrtvr•ai vs if t>t essaw. ' .
C'bhTR1t(1'1O n1rrA11.5 OP W11 (5)BPIN( A13ANiltwti) ilomrt`AT TT cTRuCTtO$s'
ritlacii hill c:614'N.iiiiir reto7rdf r rr a .iklite J r midrlph trtfrtuar of nun N>s arr pph : .. .
icel r ONl t t,tttrtts:f <Ar rre rlotit.40c r,4.vr 34rtt.,JuIr rnrr rtvrr1t rrn.t�* ;10a..1or.Ail-Weir Submit the forni withiti 3t)days of compictitia:;ot tvcll.
abandonment to the•fallow ini
tin.Wel!WL PZ-5 •:
• i)ta tslt n otW1'ah r Re out Information 'rotessm t trait.
• 161'1 Mail$01,:iei.Cen ter Ralei;lip t'iC 27699 1617
66 Teti.'-4i dipih 20- •• 00)
::itlb Torl»li'ctloin W• ts`'_In itildition to seudmg tine fonit to rite addtJ ss:.in Ida:
`abo also•submit one cope of•this;t`Orn iv tihiu 3tY;days of completion of well .
'6i Borehole diameter;:1.: Oo.}; . •abattt 0.010.1•tit the rauosstii_
I)h idea of Water Rewrite +LtnduRround Injeetiau Gemini Program,
bd.Water t escl'bel mss ground surface NA.. (t't) 1636 Mail...s64fte Center Raletglr,1iC 276991631$ .
tOe lFar:Vltater Sjiri»lr `Tnlicrinn Wells 1il addition t0 setidtng tlr> fetus to
6t=.Outercasmg length(if.laiosrn):: (ft;); ;the'idd ess(es)abode also ,thnttt;one copy` of this Ibim i dbrn 3b;h4s of
. .. rcomirletion of well ah ounientjti the county health depattarc et of•thc:eoust}':.
(ttb,.re tibando ed;. ,..,
6f.inneriatmgltubhii length(;Tknmrn) to {ft)
6g Screen length,(if tntu�tin) io ••-• (ft)`. I
FnntiftCl m NontiCarot ia.De ntir.4'. '.n lronmentmid`Natu>atTtesourm :Dhlsiol.i.af 5rmwrltccsoiiro Etetiicdlui i,s140t3_;